Abstract
Objectives:
Trauma rooms, as fast-paced and demanding health care environments, are highly susceptible to interruptions that can negatively impact workflow efficiency and patient safety. These interruptions often arise from human or environmental factors. This study investigates the role of the physical environment in influencing workflow interruptions by identifying key interruptive events in a trauma room, their primary sources, and outcomes using a pilot method of observational coding.
Methods:
This pilot study utilized video observations of 6 trauma cases in an urban level 1 trauma center. Using Noldus Observer XT 16 software, medical staff roles, interruptive events, their causes, and associated impacts were systematically coded and analyzed.
Results:
A total of 114 events were observed. The most common events included “movement restrictions” (39%), “throwing objects” (17%), and “cleaning/clearing the floor” (13%). Key causes were “clutter/untidiness” (32%) and “mobile fixture/furniture location” (21%). Frequently observed impacts included “unnecessary task additions” (21%) and “hindered task completion” (20%). The results also revealed frequent associations between causes, events, and impacts. Movement restrictions caused by clutter/untidiness often led to disentangling cables and tubing (13.2%). Similarly, movement restrictions due to mobile fixture placement required equipment repositioning in 13.2% of cases. Throwing objects, often linked to behavioral habits, contributed to clutter (16%), whereas floor clearing/cleaning due to clutter added unnecessary tasks (13%).
Conclusion:
The findings underscored the significant role of physical-environmental factors in workflow interruptions in trauma rooms. These insights can inform evidence-based design improvements and operational strategies for future enhancements, ultimately improving staff and patient outcomes in high-pressure health care settings.
Key Words: trauma room, workflow interruptions, physical environment, evidence-based design, patient safety
Trauma rooms, like other high-risk health care environments, are subject to frequent interruptions that can disrupt the workflow and potentially compromise patient outcomes.1–3 These environments are particularly vulnerable to interruptions due to the fast-paced, high-stakes nature of emergency care, where coordination among staff is critical for effective treatment. Interruptions happen when attention shifts or a break in continuity disrupts task completion.4
Frequent disruptions and interruptions, particularly in high-risk environments, increase cognitive load, hinder information processing, and reduce recovery time from interruptions. This leads to higher stress, longer surgeries, more errors, and increased patient mortality rates.5 Previous studies in acute care settings have documented how even minor disruptions can accumulate, leading to significant flow disruptions that increase the risk of medical errors and procedural delays.1,2,6,7
Although considerable attention has been given to human factors, such as communication breakdowns and task-related interruptions,8,9 the role of the physical environment in contributing to interruptions in trauma rooms remains underexplored.2 The physical environment, comprising both fixed and mobile components, includes elements such as room layout, doors, walls, lighting, integrated technologies, equipment, fixtures, and furniture.2
The layout and organization of trauma rooms, the positioning of equipment and furniture, and the availability of space all play key roles in shaping staff movements and interactions.3 Oversights in the design of these elements can lead to collisions, congestion, and other flow disruptions that hinder the efficiency of care.2 To reduce the frequency and mitigate the impact of interruptions in complex health care environments, it is essential to apply observational studies using valid and reliable assessments in real trauma rooms and analyze the common causes, impacts, and outcomes of interruptions across similar settings.2,10
This study aimed to address how physical-environmental factors contribute to workflow disruptions by identifying interruptions, categorizing them as Events, and analyzing their primary causes and impacts. This study explored these factors through a pilot method of video observations and structural coding.
METHODS
This Pilot study used a video observation method on a convenience sample of 6 recorded videos from a trauma room in an urban level I trauma center. The study obtained Institutional Review Board (IRB) approval from the health care system under study and the staff were informed and provided consent for the video recording. The recorded videos included 6 random distinct trauma cases and were captured using 5 cameras positioned in the upper corners of the trauma room and on the center of one of the walls to enhance visibility and precision in video observations; however, a few blind spots remained behind some equipment. No audio was included to reinforce the protection of staff and patient privacy. The videos were stored in a secure server located in the health care facility under study, only accessible by the medical research team members. The videos were automatically deidentified by blurring staff faces and blacking out patients. They were then carefully reviewed manually for an additional layer of privacy and ensuring no identifying information is included in the videos. The recording started from the patient’s pre-arrival and extended through their entire stay until the discharge phase when the patient was transported out of the room. Using Noldus Observer XT 16 software, the videos were then coded and analyzed (Fig. 1). The coding scheme template was developed by the research team through a review of the current literature related to trauma room design and interruptions/disruptions in health care settings. Through multiple revisions and preliminary video observations, the research team developed a template that included the most common interruptions (named as Events) in trauma rooms, the main sources of interruptions (Causes), and their potential outcomes (Impacts). The coding template was continuously revised and evolved during video observations when an unanticipated new event, cause, or impact was observed.
FIGURE 1.
Noldus Observer XT 16 software template.
Three graduate research assistants were trained to observe and code the videos. They had multiple virtual meetings with the clinical research team members to understand the roles, objects, and tasks in trauma rooms. They were also trained to use the Noldus software. Each video was observed by all research assistants under the supervision of the principal investigator to ensure the validity and reliability of the results. Through multiple review sessions, the team addressed discrepancy as part of inter-rater agreement, which was also supported by the built-in reliability feature. The research assistants initially observed the video to record each medical staff based on their role. Subsequently, they reobserved the videos, following one role at a time, to code the events (interruptions), and identify the causes of each event, and their impacts.
The observed roles include the lead surgeon, emergency medicine (EM) attending, EM resident, primary nurse, secondary nurse, float nurses, lead surgeon, senior surgery resident, junior surgery resident, respiratory therapists, EM technicians, trauma advanced practice provider (APP), scribe nurse, and pharmacist (Fig. 2). The observed trauma cases include falls, gunshot wounds, and car accidents. Events, causes, and impacts were coded based on the review of recent literature. Events refer to interruptions that occur; Movement restriction, throwing objects, cleaning/clearing floor, excessive reach for accessing patients, objects, or equipment, equipment positioning, potential collision/collision, dropping objects, and searching activity (Table 1). Causes identify the factors that led to a disruption; clutter/untidiness, mobile fixture/furniture location, behavioral, insufficient space, inefficient workspace/surface, people congestion, equipment failures, cabinet setup, fixed fixture/furniture location, and equipment or furniture positioning (Table 2). Finally, impacts were defined as the consequences resulting from the disruption event; unnecessary task/activity addition, clutter, hindered task completion, disentangling, moving equipment, people repositioning, people excessive reach, and congestion (Table 3).
FIGURE 2.
Roles and positions in a trauma room.
TABLE 1.
Definitions of Events
| Events | References | Definition |
|---|---|---|
| Movement restriction | Instances where movement is hindered, causing rerouting, difficulty in moving, or the need to untangle wires and cords. | |
| Throwing objects | Palmer et al,11 | Deliberate actions of throwing an object onto the floor. |
| Cleaning/clearing floor | Activities involving cleaning the floor or removing obstacles that impede movement or workflow. | |
| Excessive reach for accessing patients, objects, or equipment | Bayramzadeh et al,12 | Incidents in which an individual must noticeably stretch, extend their arms, or stand on tiptoe to reach a patient, object, or equipment. |
| Equipment positioning | Bayramzadeh et al,12 Palmer et al,11 | Adjusting, positioning, or repositioning equipment to achieve an exact and functional location within the room. |
| Potential collision/collision | Bayramzadeh et al,12 | Events where people collide with other people, or with objects. |
| Dropping objects | Palmer et al,11 | Accidental dropping of an object onto the floor. |
| Searching activity | Palmer et al,11 | Miscellaneous items become misplaced or unavailable and are pursued for urgent use. |
TABLE 2.
Definitions of Causes
| Causes | References | Definition |
|---|---|---|
| Clutter/untidiness | Koch et al,13 | The presence of disorganized items, such as cords, hindering the workflow. |
| Mobile fixture/furniture location | Misuse or improper placement of movable fixtures, such as carts, leading to clutter or obstruction. | |
| Behavioral | Behaviors influenced by habits, such as throwing the trash on the floor instead of trash bin. | |
| Insufficient space | A lack of adequate room for movement, standing, or working efficiently. | |
| Inefficient workspace/surface | Palmer et al,11 | Inadequate space or surfaces for placing items or equipment, or performing tasks such as preparing medication (e.g., cluttered horizontal workspaces or insufficient storage). |
| People congestion | Koch et al,13 | The presence or accumulation of multiple individuals that hinders movement or workflow. |
| Equipment failures | Palmer et al,11 Koch et al,13 | Issues or malfunctions in equipment |
| Cabinet setup | The organization of cabinets, ensuring items are easy to locate and retrieve (e.g., cabinets with labels or see-through) | |
| Fixed fixture/furniture Location | Bayramzadeh et al,12 Palmer et al,11 | The positioning of immovable furniture or fixtures, such as cabinets. |
| Equipment or furniture positioning | Bayramzadeh et al,12 Palmer et al,11 | Adjusting, positioning, or repositioning equipment and furniture to achieve an exact and functional location within the room. |
TABLE 3.
Definitions of Impacts
| Impacts | References | Definition |
|---|---|---|
| Unnecessary task/activity addition | Adding another task (e.g., cleaning the floor.) that is not essential to the primary task. | |
| Clutter | The presence of disorganized items. | |
| Hindered task completion | Prolonged task completion or difficulty in completing tasks. | |
| Disentangling | Bayramzadeh et al,12 Palmer et al,11 | The process of untangling the cords and tubing (e.g., IV tubing and medical cables). |
| Moving equipment | Pushing equipment or positioning machines/furniture that restrict movement or actions of staff. | |
| People repositioning | Individuals adjusting their position to improve access, avoid obstruction, etc. | |
| People excessive reach | Bayramzadeh et al,12 | Incidents in which an individual must noticeably stretch, extend their arms, or stand on tiptoe to reach a patient, object, or equipment. |
| Congestion | Koch et al,13 | The presence or accumulation of multiple individuals that hinders movement or workflow. |
| People detour | Anything that can cause trauma room staff to deviate from their original path. |
In addition, in the dynamic environment of trauma rooms, interruption events often unfold as a chain of consequences, where an initial event triggers subsequent ones. In this research, these sequential events are categorized into level 1 events, representing the initial interruption/disruptions, and level 2 events, which arise as their consequences.
After the videos were coded, the data were exported from Noldus Observer XT 16 to Excel for analysis. The analysis summarized the frequency of events, their causes, and impacts, along with the occurrence of level 1 and level 2 events. In addition, the analysis revealed the frequency of causes associated with each specific event and the impacts resulting from each event.
RESULTS
Our observations of 6 prerecorded trauma room videos revealed that the interruption events included: movement restriction, throwing objects, cleaning/clearing floor, excessive reach for accessing patients, objects, or equipment, equipment positioning, potential collision/collision, dropping objects, searching activity.
The causes of interruptions in trauma rooms include clutter/untidiness, which can obstruct movement and workflow; mobile fixture/furniture location, where improper placement of movable items creates barriers; Behavioral factors that influence behaviors, such as disorganized practices; insufficient space, leading to overcrowded or inefficient areas; inefficient workspace / surface, which can hinder task performance due to poor organization or inadequate surfaces; people congestion, where overcrowding limits movement and access; equipment failures, causing delays and disruptions; cabinet setup, where disorganized or poorly labeled storage complicates access to necessary items; fixed fixture/furniture location, which can restrict movement if not strategically placed; and equipment or furniture positioning, where improper arrangement of items can impede staff efficiency and patient care. These factors collectively contribute to significant workflow disruptions.
These disruptions frequently resulted in impacts unnecessary task/activity addition, clutter, hindered task completion, disentangling, moving equipment, people repositioning, people excessive reach, congestion, people detour. all of which compounded the stress and inefficiency of trauma room operations.
The frequency of observed events across different categories highlights specific patterns. Movement restriction occurred in 39% (n=45), making it the most frequent event and common challenge. Throwing objects follows with 17% (n=19), suggesting it is a recurring issue in relevant settings. Cleaning or clearing the floor is recorded at 13% (n=15), excessive reach for accessing patients, objects, or equipment is observed in 12% (n=14), and equipment positioning accounts for 10% (n=11). Less frequent events include potential collisions 3% (n=4), searching activities 3% (n=3), and dropping objects 3% (n=3). In total, 114 events were observed (Table 4).
TABLE 4.
The Frequency of Events
| Events | Frequency of events (percentages), n (%) |
|---|---|
| Movement restriction | 45 (39) |
| Throwing objects | 19 (17) |
| Cleaning/clearing floor | 15 (13) |
| Excessive reach for accessing patients, objects, or equipment | 14 (12) |
| Equipment positioning | 11 (10) |
| Potential collision/collision | 4 (3) |
| Dropping objects | 3 (3) |
| Searching activity | 3 (3) |
| Total Number of Events | 114 (100) |
The frequency of different causes highlights several key factors affecting operations. Clutter or untidiness is the most common cause, occurring in 32% (n=36). Mobile fixture or furniture location follows with 21% (n=24), behavioral factors are cited 18% (n=21), and insufficient space is noted in 7% (n=8), whereas inefficient workspace or surfaces appear in 6% (n=7), underscoring spatial challenges. Equipment failures are reported at 4% (n=5), and people congestion is noted in 5% (n=6). Less frequent causes include cabinet setup 3% (n=3), fixed fixture or furniture location 3% (n=3), and specific equipment or furniture positioning 1% (n=1). In total, these causes amount to 114 instances (Table 5).
TABLE 5.
The Frequency of Causes
| Causes | Frequency of causes (percentages), n (%) |
|---|---|
| Clutter/untidiness | 36 (32) |
| Mobile fixture/furniture location | 24 (21) |
| Behavioral | 21 (18) |
| Insufficient space | 8 (7) |
| Inefficient workspace/surface | 7 (6) |
| People congestion | 6 (5) |
| Equipment failures | 5 (4) |
| Cabinet setup | 3 (3) |
| Fixed fixture/furniture location | 3 (3) |
| Equipment or furniture positioning | 1 (1) |
| Total | 114 (100) |
This section explores the primary causes contributing to each type of interruption. The 2 major causes contributing to movement restriction are clutter or untidiness as the most frequent contributor, occurring (n=20), and mobile fixture/furniture location occurring (n=19). The only major contributor to throwing object is behavioral occurring (n=18), whereas the major contributor to cleaning/clearing floor is clutter/untidiness occurring (n=15). The primary causes affecting excessive reach for accessing patients, objects, or equipment are mobile fixture/furniture location as the most frequent contributor, occurring (n=4), and fixed fixture/furniture location occurring (n=3). Equipment failures occurring (n=5) and inefficient workspace/surface occurring (n=4) are the 2 major causes leading to equipment positioning. The major cause to potential collision/collision is behavioral occurring (n=2), whereas the major contributor to searching activity is cabinet setup occurring (n=3). In total, these 114 instances provide a detailed view of factors that hinder workflow productivity (Table 6).
TABLE 6.
The Frequency of Causes for Each Event
| Events | Cabinet setup | Clutter/untidiness | Behavioral | Equipment failures | Equipment or furniture positioning | Fixed fixture/furniture location | Inefficient workspace/surface | Insufficient space | Mobile fixture/furniture location | People congestion | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Movement restriction | 20 | 4 | 19 | 2 | 45 | ||||||
| Throwing objects | 18 | 1 | 19 | ||||||||
| Cleaning/clearing floor | 15 | 15 | |||||||||
| Excessive reach for accessing patients, objects, or equipment | 1 | 3 | 1 | 2 | 4 | 3 | 14 | ||||
| Equipment positioning | 1 | 1 | 5 | 4 | 11 | ||||||
| Potential collision/ collision | 2 | 1 | 1 | 4 | |||||||
| Dropping objects | 1 | 1 | 1 | 3 | |||||||
| Searching activity | 3 | 3 | |||||||||
| Total | 3 | 36 | 21 | 5 | 1 | 3 | 7 | 8 | 24 | 6 | 114 |
| Percentage | 3% | 32% | 18% | 4% | 1% | 3% | 6% | 7% | 21% | 5% | 100% |
The impacts of various factors on operations are categorized to highlight inefficiencies. Unnecessary task or activity addition is the most frequent impact, occurring in 21% of cases (n=24). Clutter and hindered task completion follow closely, each contributing 20% (n=23). Disentangling appears in 15% (n=17), whereas moving equipment accounts for 14% (n=16). People repositioning is observed in 6% (n=7), with excessive reach noted in 2% (n=2). Less frequent impacts include congestion 1% (n=1), and people detours 1%, (n=1). Altogether, these impacts total 114 instances (Table 7).
TABLE 7.
The Frequency of Impacts
| Impacts | Frequency of impact (percentage), n (%) |
|---|---|
| Unnecessary task/activity addition | 24 (21) |
| Clutter | 23 (20) |
| Hindered task completion | 23 (20) |
| Disentangling | 17 (15) |
| Moving equipment | 16 (14) |
| People repositioning | 7 (6) |
| People excessive reach | 2 (2) |
| Congestion | 1 (1) |
| People detour | 1 (1) |
| Total | 114 (100) |
The main consequence of cleaning/clearing floor is unnecessary task/activity addition with (n=15), whereas clutter with (n=3) is the primary consequence of dropping objects. The 2 major consequences of equipment positioning are unnecessary task/activity addition with (n=5), and hindered task completion with (n=5). Hindered task completion with (n=10), is the main consequence of excessive reach for accessing patient, object, or equipment. Disentangling with (n=17) and moving equipment with (n=15) are the 2 major consequences for movement restriction. People repositioning is noted with (n=3) as the primary consequence for potential collision/collision whereas hindered task completion with (n=3) is the primary consequence for searching activity. Finally, clutter with (n=19) is the main consequence of throwing objects Table 8).
TABLE 8.
The Impacts of Each Event
| Impacts events | Clutter | Congestion | Disentangling | Hindered task completion | Moving equipment | People detour | People excessive reach | People repositioning | Unnecessary task/activity addition | Total |
|---|---|---|---|---|---|---|---|---|---|---|
| Cleaning/clearing floor | 15 | 15 | ||||||||
| Dropping objects | 3 | 3 | ||||||||
| Equipment positioning | 1 | 5 | 5 | 11 | ||||||
| Excessive reach for accessing patient, object, or equipment | 10 | 1 | 1 | 2 | 14 | |||||
| Movement restriction | 17 | 5 | 15 | 4 | 45 | |||||
| Potential collision/collision | 1 | 3 | 4 | |||||||
| Searching activity | 3 | 3 | ||||||||
| Throwing objects | 19 | 19 | ||||||||
| Total | 23 | 1 | 17 | 23 | 16 | 1 | 2 | 7 | 20 | 114 |
| Percentage | 20% | 1% | 15% | 20% | 14% | 1% | 2% | 6% | 21% | 100% |
Table 9 illustrates the association between causes, events, and impacts. Movement restriction, the most frequent event, was linked to clutter/untidiness, leading to disentangling cords, cables, and medical tubing in 13.2% (n=15) of all 114 cause-event-impact associations. It also accounted for 13.2% (n=15) of cases due to mobile fixture/furniture location, which required moving equipment. In addition, in 3.5% (n=4) of instances, clutter/untidiness contributed to movement restriction, adding unnecessary tasks or activities. In 2.6% (n=3) of cases, movement restriction occurred due to insufficient space, consequently hindering task completion.
TABLE 9.
Events, Cause, and Impacts
Throwing objects was driven by behavioral habits and contributed to clutter in the trauma room in 15.8% (n=18) of cases. Cleaning/clearing the floor, caused by clutter/untidiness, added unnecessary tasks or activities for the medical staff in 13.2% (n=15) of cases. This was the only cause and impact identified for this event. Excessive reach to access patients, objects, or equipment was attributed to mobile fixture/furniture location in 2.6% (n=3) of cases, which hindered task completion. An additional 2.6% (n=3) of cases arose from people congestion, again obstructing task completion.
Equipment positioning, caused by equipment malfunction and resulted in unnecessary tasks or activities, accounted for 2.6% (n=3) of cases. In 2.6% (n=3) of cases, searching activity was caused by the cabinet setup, which obstructed task completion. Other cause-event-impact associations are included in Table 9, each representing less than 2% of all events (n=1 or 2).
Table 10 summarizes the distribution of the sequential events, which are categorized into level 1 and level 2 events. Throwing objects emerged as the most frequent level 1 event, leading to further interruptive/disruptive events 14 times. Cleaning or clearing the floor was the predominant Level 2 event, recorded 12 times as a consequence of level 1 events. Dropping objects initiated further events on 3 occasions, whereas equipment positioning acted as a level 1 event twice. Conversely, movement restriction was noted as a level 2 event in 8 instances, followed by equipment positioning and excessive reach for accessing patients, objects, or equipment, recorded twice and once, respectively.
TABLE 10.
Frequency of Level 1 and Level 2 Events.
| Events | Level 1 | Level 2 | Grand total |
|---|---|---|---|
| Cleaning/clearing floor | 12 | 12 | |
| Dropping objects | 3 | 3 | |
| Equipment positioning | 2 | 2 | 4 |
| Excessive reach for accessing patient, objects, or equipment | 1 | 1 | |
| Movement restriction | 8 | 8 | |
| Throwing objects | 14 | 14 | |
| Grand total | 19 | 23 | 42 |
Table 11 illustrates the relationship between level 1 and level 2 events. Cleaning or clearing the floor, as a level 2 event, occurred 9 times as a consequence of a throwing object event and 3 times after a dropping object event. Equipment positioning, as a level 2 event, was recorded twice, both resulting from incorrect equipment positioning at level 1. Excessive reach for accessing patient, objects, or equipment, as a level 2 event, occurred once due to a prior equipment positioning issue. Finally, movement restriction, as a level 2 event, was triggered 4 times by equipment positioning, 3 times by throwing objects, and once by cleaning or clearing the floor as a level 1 event.
TABLE 11.
Association Between Level 1 and 2 Events
| Level 1 Level 2 |
Cleaning/clearing floor | Dropping objects | Equipment positioning | Throwing objects |
|---|---|---|---|---|
| Cleaning/clearing floor | 3 | 9 | ||
| Dropping objects | ||||
| Equipment positioning | 2 | |||
| Excessive reach for accessing patient, objects, or equipment | 1 | |||
| Movement restriction | 1 | 4 | 3 |
DISCUSSION
The current literature encompasses issues around interruptions and disruptions in various environments but lacks emphasis on how such interruptions can stem from the physical environment. This pilot study aimed to examine critical workflow inefficiencies in trauma rooms, emphasizing the interconnectedness of interruption events, their underlying causes, and their operational impacts using a proposed method of video observation and structured coding. These findings reveal how physical, spatial, behavioral, and organizational factors converge to disrupt processes in high-stakes environments. The discussion interprets these results to offer a deeper understanding of the challenges faced in trauma rooms and suggests potential areas for improvement.
Movement restriction emerged as the most frequent event, featuring a common challenge in trauma room environments. This issue is significant in trauma rooms due to the critical need for seamless mobility to deliver timely care. Barriers such as clutter and misplaced mobile fixtures create unnecessary obstacles, forcing staff to disentangle cords, reposition equipment, and navigate crowded spaces. These disruptions not only waste valuable time but also divert focus from patient care.
Another significant finding is the prevalence of throwing objects, driven by embedded habits and behaviors. Although such behaviors may be perceived as a means of expediting tasks, it often results in follow-up tasks such as subsequent cleanup as a result of clutter, creating a ripple effect of inefficiency. Similarly, cleaning or clearing the floor, largely resulted from clutter, adds to the burden on staff, further diverting their attention from critical responsibilities.
Excessive reach for accessing patients, objects, or equipment highlights another significant spatial inefficiency. When equipment and furniture are poorly positioned, staff need to work harder to perform basic tasks, increasing physical strain and delaying workflow. Equipment positioning issues, frequently caused by equipment failures or inadequate workspace designs, extend these challenges by disrupting task sequences and requiring restorative measures. These findings are aligned with the current literature indicating that a thoughtful layout design and seamless access to resources can decrease interruptions.14 Strategizing the placement of mobile and fixed fixtures, ensuring ergonomic workspace configurations, and implementing effective storage solutions can reduce physical obstructions. Decluttering protocols is also essential for addressing movement restrictions and improving accessibility.
The causes of these events reveal the multifaceted nature of workflow inefficiencies in trauma rooms. Clutter stood out as the most common contributors, emphasizing the importance of maintaining organized environments. Mobile fixtures and furniture, although intended to enhance flexibility, often became problematic when not strategically placed, obstructing movement and access.
Behavioral factors also played a key role in causing events such as potential collisions, particularly through behaviors such as wandering around the room or throwing objects. These findings suggest that behavioral norms and habits within the trauma room setting need to be further examined and addressed through training and the establishment of standardized protocols at the organizational level as well as teamwork.15 Other contributing factors, such as insufficient space, inefficient work surfaces, and disorganized cabinet setups, highlight the need for better spatial planning and ergonomic design.
Addressing habits and established behaviors through training and reinforcement is critical. Encouraging staff to adopt practices that prioritize efficiency and organization over momentary convenience can help minimize interruptions caused by behavioral habits. Clear guidelines for equipment and furniture placement, coupled with regular training for staff, can standardize workflows and as a result mitigate inefficiencies. By fostering a culture of organization, teams can adopt practices that enhance overall efficiency.
The events observed in this study had a range of impacts on trauma room operations, resulting in inefficiencies and increasing staff stress. Among these, the addition of unnecessary tasks or activities was the most frequent impact, resulting from events like cleaning floors, repositioning equipment or staff, and disentangling cords. The current literature also supports that the accumulation of these added tasks reduces the efficiency of similar complex environments, reducing the team’s ability to respond effectively to patient needs.1,2,6,7
Clutter is known to lead to congestion or hindering tasks according to the literature.2,11 The current study revealed that clutter, a recurring event, not only hindered task completion but also increased the cognitive and physical demands on staff. Disentangling cords and cables, often required due to movement restrictions, demonstrates how seemingly minor interruptions can escalate into time-consuming inefficiencies. The need for excessive reach, frequent repositioning, and detours to access necessary items further highlights the operational strain caused by poor spatial organization.
The analysis of sequential events revealed a cascading effect, where one event triggers another. For example, throwing objects frequently acted as an initial trigger, leading to subsequent events such as cleaning or clearing the floor. Dropping objects also initiated additional events, illustrating how primary inefficiencies can spread throughout the trauma room workflow. Movement restriction, often observed as a level 2 event, was commonly caused by earlier issues such as clutter or equipment mispositioning. Similarly, the current research literature shows that accumulation of minor interruptions can lead to major disruptions.5 This sequential relationship highlights the importance of addressing root causes rather than only managing their impacts or level 2 events. Preventing primary triggers can significantly reduce the frequency and impact of subsequent events, creating a more streamlined and efficient care processes.
Lastly, the methodology used in this pilot study, including the developed coding scheme, deemed effective in unveiling complexities in the relationship between causes and impacts of interruptive events. However, this pilot study comes with limitations. Given the pilot nature of the study, a limited number of trauma cases were observed, which may limit the generalizability of the findings. Further, future research should include a diverse range of health care systems in the study to support generalizability. The observations were based on prerecorded videos, which may not capture the full range of real-time dynamics in trauma rooms. This pilot study provides a solid foundation for further research in this area. Future research could build on these results by observing more videos to develop a more robust set of data using the same methodology including the coding scheme used in this study. Potentially, observing videos across various health care systems could help with generalizability.
CONCLUSION
The preliminary findings of this pilot study carry important implications for both the design and management of trauma rooms. The data also provided insights into the relationships between causes, events, and impacts, as well as the connection between level 1 and level 2 sequential events. Addressing the causes of events requires a comprehensive approach that integrates physical design improvements with organizational and behavioral changes.
Footnotes
This project was supported by grant number R18HS027261 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
The authors disclose no conflict of interest.
Contributor Information
Sara Bayramzadeh, Email: sbayramz@kent.edu.
Parnia Azini, Email: pazini@kent.edu.
Elaheh Malek Zadeh, Email: emalekza@kent.edu.
Haya Mehar Mohammed, Email: hmoham10@kent.edu.
Ali F. Mallat, Email: mallata2@ccf.org.
Jessica Krizo, Email: KRIZOJ@ccf.org.
Steven Brooks, Email: BrooksS4@ccf.org.
REFERENCES
- 1. Göras C, Olin K, Unbeck M, et al. Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study. BMJ Open. 2019;9:e026410. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Bayramzadeh S, Anthony MK, Sterling M, et al. The role of the physical environment in shaping interruptions and disruptions in complex health care settings. Am J Med Qual. 2021;36:449–458 . [DOI] [PubMed] [Google Scholar]
- 3. Heinke TL, Joseph A, Carroll D. Safety in health care. Anesthesiol Clin. 2023;41:789–801. [DOI] [PubMed] [Google Scholar]
- 4. Craker NC, Myers RA, Eid J, et al. Nursing interruptions in a trauma intensive care unit. J Nurs Adm. 2017;47:205–211. [DOI] [PubMed] [Google Scholar]
- 5. Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Qual Saf. 2019;28:276–283. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Zjadewicz K, Deemer KS, Coulthard J, et al. Identifying what is known about improving operating room to intensive care handovers: a scoping review. Am J Med Qual. 2018;33:540–548. [DOI] [PubMed] [Google Scholar]
- 7. Al-Hakim L, Wang M, Xiao J, et al. Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures. Surg Endosc. 2019;33:3673–3687. [DOI] [PubMed] [Google Scholar]
- 8. Wahr JA, Prager RL, Abernathy JH, et al. Patient safety in the cardiac operating room: human factors and teamwork. Circ. 2013;128:1139–1169. [DOI] [PubMed] [Google Scholar]
- 9. Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, performance, and satisfaction outcomes in the operating room: a literature review. HERD. 2018;11:137–150. [DOI] [PubMed] [Google Scholar]
- 10. Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: a prospective observational study of triggers and effects of tense communication episodes in surgical teams. Lau F, editor. PLoS One. 2019;14:e0226437. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Palmer G, Abernathy JH, Swinton G, et al. Realizing improved patient care through human-centered operating room design: a human factors methodology for observing flow disruptions in the cardiothoracic operating room. Anesthesiol. 2013;119:1066–1077. [DOI] [PubMed] [Google Scholar]
- 12. Bayramzadeh S, Joseph A, San D, et al. The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioral Mapping Study. HERD. 2018;11:124–138. [DOI] [PubMed] [Google Scholar]
- 13. Koch A, Quartucci C, Buchner A, et al. Associations of flow disruptions with patient, staff, and process outcomes: a prospective observational study of robotic-assisted radical prostatectomies. Surg Endosc. 2023;37:6964–6974. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Bayramzadeh S, Chiu LYT. The impact of design on workflow: a comparative case study of level I trauma rooms. Facil. 2022;40:475–494. [Google Scholar]
- 15. Gangi A, Blaha J, Law KE, et al. Standardized teamwork training improves trauma workflow. J Surg Res Academic Press. 2014;186:657–658. [Google Scholar]